Managers can help ease staff-resident clashes
October 1, 1999
Managers can help ease staff-resident clashes
Are your nurses and residents caught in a turf war? Supervisors can prevent clashes between medical residents and nursing staff by intervening early and setting clear limits on job performance, supervisors say.
Conflicts between physicians completing their residency in critical care and seasoned unit RNs are rare. But occasionally, confrontations over lines of authority and responsibility flare up.
The best preparation for these incidents is to establish clear policies that spell out the unit’s expectations on professional collaboration, says Kathleen J. Arnold, RN, MSA, CAN, adult critical care manager at Swedish American Health System in Rockford, IL, a 525-bed teaching hospital.
When they occur, these conflicts can disrupt a unit’s natural workflow, upset patients and other staff, and bring unwelcome attention from outside administrators.
Many times a medical or residency director’s involvement may be desirable, Arnold says. An administrative physician’s actions are certain to be swift and effective, and it is a physician issue anyway. But most turf battles can be prevented without outside involvement by resorting to early preparation from a firm, yet tactful head nurse.
If the advice rings of a parent-child management problem, at times it does resemble that type of conflict resolution, some nurses suggest.
"The more residents can see as clear-cut rules, the more they are likely to understand and accept," observes Marilyn Hravnak, MSN, CRNP, CCRN, a nurse practitioner at the University of Pittsburgh School of Nursing. Hravnak co-authored a 1998 study of patient outcomes using medical residents.1
These territorial disputes can occur in any hospital department. Many times, they involve negative attitudes and resistance from individual residents who don’t want to be there or don’t like veteran nurses "pulling rank" on them, Arnold observes.
However, ICUs are not the kind of settings that can withstand interpersonal bickering for too long or delays in patient care over professional disagreements, Arnold notes.
"The pace and intensity of the ICU is too great to afford these interruptions," Arnold says. Also, many ICUs are physically small spaces and private conflicts can quickly turn into public matters, others note.
To prevent such professional spats, Arnold and Hravnak offer the following guidelines:
• Resident orientations.
Three years ago, clinicians at Swedish American implemented a third-year rotation for family practice residents through the hospital’s 20-bed medical-surgical and cardiac ICU. The program involved sending one resident at a time through the three-week rotation.
Each rotation begins with a thorough orientation session that includes a unit tour conducted by a nurse manager and packet of information outlining the three-week syllabus and exactly what is expected of each resident, Arnold says. "That way there is no misunderstanding at the outset," she adds.
Personally introduce residents to staff
• Exposure to unit staff and systems.
The orientation should include information about the nursing structure with the names and titles of nurses and other staff spelled out for residents, Hravnak advises.
The tour should include a personal introduction to each of the unit’s on-duty staff. The sooner they become acquainted with all facets of the unit’s operation and personnel on a personal level, the easier their adaptation will be, Hravnak adds. The same goes for administrative personnel.
• Unit statistics.
Hravnak also advises that managers provide each resident with copies of the unit’s clinical data and reports. Admissions and discharge data will be important to them. But equally significant are details on average census, length of patient stays, and transfer data.
Specific information on nursing procedures and individual clinical approaches such as standing protocols on heparin infusion or standard responses to atrial fibrillation are also helpful, Hravnak notes.
Each resident also reviews each patient’s chart with an RN. "The goal is to establish parameters and open communication," she says.
• Daily rounds.
At Swedish American, each resident is required to go on daily ICU rounds with clinicians accompanied at times by the residency program director, Eugene Silva, MD.
The rounds help to make residents feel like a part of the patient management team, and gets them better acquainted with the nursing staff and daily routine, says Arnold. Residents also participate in physician and nurse consults.
• Nurse compliance.
At the same time, staff RNs need to keep the presence of residents in perspective, Hravnak notes. They are physician-trainees with a certain knowledge base who are there to gain practical experience, she says.
"Nurses must do their part and follow through on the resident’s management plan. If they have questions or objections, they need to bring them to the resident’s attention, but in a collegial approach," Hravnak notes.
They also have an enormous opportunity to teach, which can bring nurses considerable satisfaction, Hravnak adds.
• Disciplinary action.
There will be those few residents, however, who will fail to conform or follow through on expectations, Arnold says. "They will fail to show up or will require phone calls to locate them throughout the hospital," she says.
These errant physicians will need a firm but tactful talking-to before a manager notifies a medical director. One effective tip is to discuss the questionable behavior or attitude with the physician while referring to the expectations each resident received on day one, Arnold says.
But sooner or later, a physician administrator will have to be consulted regarding the resident’s conduct.
• Nurse physician evaluations.
This is one reason that ICU nurses at Swedish American are asked to complete an appraisal form on each resident. (See sample report inserted in this issue.) The form evaluates each physician on key aspects of staff interactions, and gives the residency director more than one viewpoint on the resident’s progress in rotation, Arnold states.
Finally, keep in mind that the manager’s job is to greet residents and make them feel welcome while giving them ample time to comprehend expectations, Hravnak says. "The idea is to waste little time in setting up a relationship between the resident and your staff," she notes.
Reference
1. Rudy EB, Davidson LJ, Daly B, et al. Care activities and outcomes of patients cared for by acute care nurse practitioners, physician assistants, and resident physicians: A comparison. Am J Crit Care 1998; 7:267-281.
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